Filing Details

Accession Number:
0001185185-21-001179
Form Type:
4
Zero Holdings:
No
Publication Time:
2021-08-23 18:33:23
Reporting Period:
2021-08-20
Accepted Time:
2021-08-23 18:33:23
SEC Url:
Form 4 Filing
Issuer
Cik Name Symbol Sector (SIC) IRS No
1138476 Pacific Health Care Organization Inc PFHO Services-Misc Health & Allied Services, Nec (8090) 870285238
Insiders
Cik Name Reported Address Insider Title Director Officer Large Shareholder Other
1271519 Tom Kubota 2618 San Miguel Drive, #477
Newport Beach CA 92660
Ceo & President Yes Yes Yes No
Reported Non-Derivative Transactions
Sec. Name Acquisiton - Disposition Date Amount Price Remaning Holdings Equity Swap Involved Form Type Code Nature of Ownership Explanation
Common Acquisiton 2021-08-20 11,000 $1.01 7,908,000 No 4 P Direct
Equity Swap Involved Form Type Code Nature of Ownership Explanation
No 4 P Direct
Reported Derivative Holdings
Sec. Name Sec. Type Price Date Expiration Date Amount Remaning Holdings Nature of Ownership
Common Stock Series A Preferred $0.00 16,000 16,000 Direct
Expiration Date Amount Remaning Holdings Nature of Ownership
16,000 16,000 Direct
Footnotes
  1. The Reporting Person holds the shares through the Tom Kubota Revocable Trust of 2013 (the "Trust"). The Reporting Person is the sole Trustee of the Trust. As such, the Reporting Person may be deemed to have voting and/or investment power over the shares held by the Trust and therefore may be deemed to be the beneficial owner of those shares.
  2. The Series A Preferred Stock converts into Common Stock of the Issuer on a 1:1 basis at any time at the election of the Reporting Person and has no expiration date.